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					Form B. Request for Academic Salary Adjustments Only
(Note: This form does not apply to specific Chancellorial Commitments to the Schools or Institutional FTEs)



Appointee Name:                                                                                                                   Employee UID# (optional):

School/Dept:

Funding for (please check one and provide additional information as requested):
                       Exceptional Increase (applies to off & above scale increases, not change in rank or step)*
                       Executive Merit (Dean, Provost)*
                       Academic Merit (change in Step, please provide:)*
                             Previous Title and Step
                             New Title and Step
                       Promotion (change in Rank, please provide:)*
                             Previous Title and Step                                                               Previous Title Code
                             New Title and Step                                                                        New Title Code
                       Range Adjustment*
                       Turnovers Savings Withdrawal (please provide:)
                             Annual Salary                                                                     **
                             Base Rate                                                                         **
                       Up or Downgrade of new ladder Faculty appointment (please provide:)
                        Discipline/field of approved search                                                           From Base Rate
                        Search Tracking number                                                                   To New Annual Salary
                                (does not apply to most Health Science appointments, except interdisciplinary)
                               Change of status to a Center at                                                                          % time
                                         or from a Center at                                                                            % time
                               **For change of status, please also complete the 2 Turnover Savings Withdrawal boxes above regarding the Annual & Base rate
                               Other change of status involving                                                                          % time
                                  (explain change of status:)
                               **For change of status, please also complete the 2 Turnover Savings Withdrawal boxes above regarding the Annual & Base rate


Effective date:

                                                                                               Temporary Amount                            Permanent Amount
FAU/Amounts:              4-

*Please provide current Fiscal Year salary rates (if retroactive to prior FYs, also indicate year):
Old Rate at July 1
Old Rate at Oct 1                                                                                                                       Please forward completed forms & documentation to:
New Rate at July 1                                                                                                                       Academic Planning & Budget Ofc
New rate at Oct 1                                                                                                                        Doris Wang       dwang@ponet.ucla.edu
                                                                                                                                         2107 Murphy Hall
                                                                                                                                         Campus mail code 140501
Prepared by:
Extension:
Date:
  APB
use only       reto 7/1/04
A185       B
A052       B
A050       4



A049       B



A040       6
A051       B
A002
A009
A011       B
A002

				
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